ANATOMIC STUDY
Extracranial Microanatomic Study of
Supraorbital Keyhole Approach
Yixin Lin, MD,*Þ Weiqiao Zhang, MD,* Qizhong Luo, MD,* Jiyao Jiang, MD, PhD,*
and Yongming Qiu, MD, PhD*
Objective: The extracranial microanatomic features and tissue
protection for supraorbital keyhole approach are described in detail
to achieve less invasiveness, which has scant reports and is important
for craniofacial surgeons.
Methods: Ten formalin-fixed human cadaveric heads were used in
20 sides, by means of an operating microscopic, with microinstru-
ments and magnification ranging from 3 to 16. The relationship
between concerned nerves, muscles, and bone window was identified
and measured.
Results: The height from the musculus orbicularis oculi superiorus
to the incision on the arch of the eyebrow is 6.9 T 1.0 mm. The
horizontal distance from the anterior ramus of the temporal branch
of the facial nerve to the frontal zygomatic process is 19.5 T 3.6 mm.
Thus, the supraorbital keyhole approach incision can potentially
injure the nerve. However, the lateral branch of the supraorbital
nerve is outside the pericranial layer and has no ramus within 10 mm
from its emission, and the angle from the lateral branch of the su-
praorbital nerve to the ridge of the orbit is 74 T 3 degrees. Therefore,
the supraorbital nerve can be dissected to enlarge the medial region
of the bone window. We propose to form the muscle-bone flap to
keep adhesion of the temporal muscle and gain cosmetic benefit.
Conclusins: Our microanatomic study of the musculus orbicularis
oculi, the temporal branch of the facial nerve, the superior orbital
nerve, and the temporal muscle suggests a means to minimize
invasiveness and gain cosmetic benefit.
Key Words: Anatomic study, supraorbital keyhole approach,
minimally invasiveness
(J Craniofac Surg 2009;20: 215Y218)
T he supraorbital keyhole approach (SOKA) for the surgery of
anterior communicating aneurysm and olfactory sulcus menin-
gioma, as well as pituitary adenoma, is the product of continuous
development in minimally invasive neurosurgery.1 When compared
From the *Department of Neurosurgery, Ren Ji Hospital, Shanghai Jiaotong
University School of Medicine, Shanghai, and †Department of Neurosurgery,
Jin Ling Hospital, Nan Jing, China.
Received March 17, 2008.
Accepted for publication Apr. 5, 2008.
Addres correspondence and reprint request to: Dr. Yongming Qiu,
Department of Neurosurgery, Ren Ji Hospital, 1630 Dong Fang Rd,
Shanghai 200127, P. R. China; E-mail: Qiuzhoub@hotmail.com
The project was supported by the Shanghai Public Health Bureau
(no. 01457).
Copyright * 2009 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0b013e318191cf8a
The Journal of Craniofacial Surgery & Volume 20, Number 1, January 2009
Copyright @ 2009 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
with traditional craniotomy, SOKA, shown in Figure 1, has the
following advantages: (1) has a suitable direction of access, (2)
reduces the size of the craniotomy and decreases brain exposure and
damage, and (3) has less need for brain retraction. Many cases of
SOKA operation have been performed2Y4; meanwhile, there have
been some reports of temporary or permanent frontalis muscle
paralysis after using this approach,5,6 which also occurred in our
department before this study. But to our knowledge, no studies of
extracranial anatomy have been performed for the benefit of
neurosurgeons unfamiliar with this region, although intracranial
endoscopic structures and techniques have been described in detail
by Perneczky et al.7
MATERIALS AND METHODS
Ten adult cadaver specimens were dissected under 3 to 16
magnification. Colored silicone was injected into the vascular
structures. A stainless 3-pin head clamp system was used to fix the
head, and a high-speed drill was used to open the keyhole
(STRONG108; Sae Sha Precision Industrial Co, Daegu, Korea).
Microanatomic stepwise dissections were performed using an
operating microscope (SOM-12 NEURO; Karl Kaps GmbH & Co,
Asslar, Germany) equipped with a digital camera.
A 5-cm skin incision was made along the superciliary arch,
from the medial third of the orbit and extending laterally, dissecting
the skin and exposing the orbicularis oculi muscle. The height of the
orbicularis oculi muscle above the incision was measured (Fig. 2).
An acute question-mark incision was made from the paramidline
forehead posterior and inferior to the front of the ear and then under
the ear, exposing the facial nerve at the stylomastoid foramen and
tracking its course to the parotid gland. Below the zygomatic arch,
the parotideomasseteric fascia was used to identify the temporal
branch of the facial nerve, and its anterior ramus was dissected under
surgical microscopy up to the level of the superciliary arch, where its
distance from the zygomatic process of the frontal bone was
measured (Fig. 3). Then, in all 10 specimens, an incision was made
in the orbicularis oculi muscle deep to the frontal bone, dissecting
the pericranium and exposing the frontal bone. Using the same
method, the dissection proceeded medially up to the point of the
supraorbital foramen/notch. The lateral branch of the supraorbital
nerve was dissected for approximately 10 mm, and its course
observed, and the angle between the nerve and the supraorbital
margin was measured. The distance between the supraorbital
foramen/notch and the zygomatic process of the frontal bone was
also measured. The above extracranial dissection results were used
in devising a method to minimize trauma during surgery.
All measurement data were analyzed using the SAS System
for Windows V6.12 statistical software, and numerical data were
expressed as mean T SD.
RESULTS
Posterior to the zygomatic process of the frontal bone, the
anterior ramus of the temporal branch of the facial nerve crosses the
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Lin et al The Journal of Craniofacial Surgery & Volume 20, Number 1, January 2009

FIGURE 1. A schematic of the location and size of the bone window in SOKA. A, A bone hole is drilled on the supraorbital
margin of the frontal bone, and the bone flap as removed by a milling cutter is shown on the right. B, Bone window of a
specimen. The arrowheads indicate its border, and the dura has been reflected. Du indicates dura; FL, frontal lobe; BH, bone
hole; BF, bone flap.

superior border of the zygomatic arch anteriorly and medially and
proceeds in an oblique fashion anteriorly and superiorly. It gives off
many small branches along its course (Fig. 3), supplying the
orbicularis oculi muscle and the forehead muscles of facial
expression. Branches supplying the superior part of the orbicularis
oculi muscle do not stray past the upper margin of the muscle, and
distances between the frontalis muscle branch and the zygomatic
process of the frontal bone are shown (Table 1). In the specimens, a
supraorbital foramen was observed in 8 of 20 sides, and a
supraorbital notch was observed in 12 of 20 sides. The lateral
branch of the supraorbital nerve courses laterally and superiorly on
the pericranium within 10 mm of its emission from the supraorbital
foramen/notch, with no branches. Its angle with the supraorbital
margin was 74 T 3 degrees (range, 68Y80 degrees). The dissected
supraorbital nerves were preserved in their original conditions and
not resected. The measurements are shown in Table 1.
DISCUSSION
The aim of refinements in supraorbital approach is to
minimize trauma while still attaining acceptable outcomes. Recent
development in neurosurgery, especially development in medical
imaging techniques and the revival of endoscopy in neurosurgery
and its combination with microscopy (endoscope-assisted micro-
neurosurgery) greatly facilitated the development of SOKA
requiring even smaller incisions.8 The first cadaveric studies aimed
at treating ventral brainstem pathologies via endoscope-assisted
SOKA occurred less than 10 years ago.9,10
The incision for SOKA lies on the superciliary arch and not
on the scalp. Because facial muscles and sensory and motor nerves
supplying the forehead are in close proximity to the incision,
unfamiliarity with local anatomy could result in cosmetic problems.
Therefore, we undertook a study of the extracranial anatomy of
SOKA. In the literature, the only extracranial point of attention for
this approach is listed as avoiding damage to the supraorbital
nerve,11 but our study found that, to minimize invasiveness, preserve
cosmetic features, and reduce the occurrence of complications such
as frontalis muscle paralysis, there are 4 extracranial anatomic
structures worth noting in this approach. They are the orbicularis
oculi muscle, the temporal branch of the facial nerve, the
supraorbital nerve, and the temporalis muscle.
The orbicularis oculi muscle is closely associated with the
skin and is divided as a palpebral part (annular, enclosing the
palpebral fissure), an orbital part (annular, enclosing the orbit), and a
lacrimal part (fascicular). It has been reported that the orbicularis
oculi muscle is cut with the skin when making the skin incision
during SOKA. In our measurements, the height of the superior part
of the orbicularis oculi muscle above the incision was 6.9 T 1.0 mm.
This shows that, if the depth of incision reaches to bone medium, the
orbicularis oculi muscle fibers above the incision are severed. To
prevent this, the skin incision should be performed gently to reach
the surface of the orbicularis oculi muscle, and the skin and the
orbicularis oculi muscle should be separated superiorly. Then, an
arched incision following the superior fibers of the orbicularis oculi
muscle is made deep to the pericranium, pushing the myoperiosteal
layer to the orbital margin. This can reduce the number of orbicularis
oculi muscle fibers severed, aiding in retaining the function of the
orbicularis oculi muscle and also in anatomical realignment and
layer preservation during suturing.
At present, there are no published reports of the relationship
between the temporal branch of the facial nerve and SOKA. Some
authors believe that SOKA does not affect the branches of the facial
nerve and hence cannot result in facial paralysis,11,12 although there

FIGURE 2. Relationship between the orbicularis oculi muscle and the incision (right). The arrowheads indicate the upper
margin of the orbicularis oculi muscle, and the black line is the direction of the incision. It can be seen that both are above
the incision. A, The skin above the incision has been reflected to reveal the upper margin of the orbicularis oculi muscle. B,
The upper margin of the orbicularis oculi muscle in the actual incision. An incision made parallel to the muscle fibers can
avoid severing the orbicularis oculi muscle.

216 * 2009 Mutaz B. Habal, MD

Copyright @ 2009 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

The Journal of Craniofacial Surgery & Volume 20, Number 1, January 2009
FIGURE 3. Course of the anterior ramus of the temporal branch of the facial nerve. The arrowheads indicate the course of
its main stem. Image (B) is a local magnification of image (A), and many small branches can be seen along the course of the
main stem. F indicates frontalis muscle branch of the facial nerve; O, orbicularis oculi muscle branch of the facial nerve; OM,
orbicularis oculi muscle.
have been cases with temporary or permanent loss of forehead
wrinkling,5,6 demonstrating that SOKA has the potential to damage
the frontalis muscle branch of the facial nerve. Our study showed that
the distance between the anterior ramus of the temporal branch of the
facial nerve as distributed on the forehead and the zygomatic process
of the frontal bone was 19.5 T 3.6 mm (range, 12.7Y23.7 mm). This
indicates that if the incision is made more than 13 mm lateral to the
zygomatic process, there is a risk of damaging the frontalis muscle
branch, which arises from the anterior ramus of the temporal branch
of the facial nerve. Therefore, in surgeries requiring laterally
extended incisions for the construction of a frontolateral bone flap,
particular attention must be given to the possibility of damaging the
frontalis muscle branch of the facial nerve. Wilson13 believes that
the frontalis muscle branch of the facial nerve has 1 to 3 branches on
the tragusYlateral canthus line. For cases with 2 or 3 branches, the
nerve fibers form a plexus, while damaging 1 branch does not result
in total facial paralysis. However, cases with only 1 branch comprise
about one third in our cadaveric study, with no anastomoses, and
damage results in frontalis muscle paralysis and loss of wrinkling. In
SOKA, we are most concerned with branches of the anterior ramus,
and branches of the posterior ramus were not tracked. However, by
following the course of the anterior ramus, we found many small
branches along its course, which may be the anastomotic branches
referred to by Wilson. Therefore, there exists the possibility of
damaging the most anterior part of the frontalis muscle branch
without resulting in total paralysis of the frontalis muscle, which also
explains the clinical observation that the occurrence rate of frontalis
muscle paralysis after SOKA is not high, and recovery after
temporary paralysis is observed in some cases.
It is commonly believed that the SOKA incision must be
made lateral to the supraorbital foramen/notch to prevent damage to
the supraorbital nerve.11 However, this limits surgeries that require
the bone window to be more medial to a suboptimal approach. To
overcome this limitation, some surgeons perform an additional
vertical incision. However, vertical skin incisions are parallel to skin
tension lines, are made blindly, and might damage the underlying
supraorbital nerve. Our study found that after leaving the
supraorbital foramen/notch, the supraorbital nerve courses on the
pericranium, and its lateral branch does not give off branches in
the first 10 mm of its course superiorly, and the angle it made with
the supraorbital margin was 74 T 3 degrees (range, 68Y80 degrees).
Therefore, we believe that more medial bone windows are required
during SOKA, which can be done as follows. The medial border of
the incision is made 1 cm medial to the supraorbital foramen/notch.
After the skin is dissected to the orbicularis oculi muscle, the fascia
of the supraorbital margin is cut lateral to the superciliary arch, deep
to the frontal bone. The incision is continued under the pericranium,
* 2009 Mutaz B. Habal, MD
Copyright @ 2009 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Extracranial Microanatomic Study of
Supraorbital Keyhole
following the supraorbital margin and proceeding medially, cutting
and dissecting the pericranium, until the supraorbital foramen/notch
is exposed, when approximately 10 mm of the supraorbital nerve is
dissected superiorly. This approach achieves 3 objectives: (1) the
supraorbital nerve is freed and not pulled during skin retraction,
preventing injury; (2) depending on the need, the bone window can
be made more medially, even made posterior to the supraorbital
nerve; and (3) it avoids vertical skin incisions, which are perpen-
dicular to the skin tension lines and damage cosmetic appearance.
Experiments have demonstrated that this method is completely
feasible, and anatomic preservation of the supraorbital nerve can be
achieved. However, clinical examinations must be performed to
determine whether it has any effect on supraorbital nerve function.
The SOKA has 3 types of bone flaps: frontomedial,
frontosupraorbital, and frontolateral bone flaps. The frontomedial
bone flap does not reach the temporal line, and the temporalis muscle
does not need to be dissected. Frontosupraorbital and frontolateral
bone flaps require different degrees of frontalis muscle dissection.
The standard dissection method is cutting the temporalis muscle
fascia on the temporal line, and depending on the location and area of
craniotomy, the temporalis muscle is blunt dissected for 1 to 2 cm to
drill the bone hole posterior to the frontal bone superior temporal
line. This method requires partially separating the temporalis muscle
from its attachment on the frontal bone superior temporal line, which
is more damaging and may affect the temporalis muscle realignment,
reattachment, and appearance after surgery.
Preservation of the temporalis muscle attachment on the
temporal line can be achieved in the following ways. The drill hole
site on the skull is made medial to the incision. Following the planned
upper bone window margin, the incision is made deep to the bone
medium following the temporal line. At this point, the temporalis
muscle is cut deep to the bone medium parallel to the direction of the
TABLE 1. SOKA-Related Anatomical Parameters (20 Sides)
Measurement Maximum Minimum
Item Mean SD value value
HO 6.9 1.0 8.3 4.9
ATF-ZF 19.5 3.6 23.7 12.7
SO-ZF 30.6 1.6 33.0 26.4
Values are in millimeters.
HO indicates height of the orbicularis oculi muscle above the incision;
ATF, anterior ramus of the temporal branch of the facial nerve; ZF, zygomatic
process of the frontal bone; SO, supraorbital foramen/notch.
217
Lin et al The Journal of Craniofacial Surgery
muscle fibers, and after slightly separating the temporalis muscle, an
abrasion drill or a pendulum saw is used to saw-open the bone
medium, with the length depending on the requirement of the
bone window. Then, the bone is sawn along the planned lower bone
window margin to the temporal line, and the bone medium is sawn
using the same method, parallel to the direction of the muscle fibers.
Finally, the bone flap is avulsed externally at the site of the bone hole
and reflected inferiorly with the attached temporalis muscle. This
method preserves the attachment of the temporalis muscle on the
frontal bone and facilitates the total realignment and complete
functional preservation of the temporalis muscle.
CONCLUSION
We have detailed the extracranial anatomic features of SOKA.
Knowledge of the surgical anatomy of this region is important for
the surgical management of SOKA.
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* 2009 Mutaz B. Habal, MD